Identity

Name
RM
Age
Address
Admitted

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:
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Mrs. M
11-66-29
35 y.o
lingsar, west lombok
22nd December 2014

G3P2A0L2 S/L/IU 39-40 weeks head presentation with PROM < 12

hour + susp. macrosomia

TIME

SUBJECTIVE

22nd
Decem
ber
2014

Patient referred from Lingsar

PHC with G3P2A0L2 S/L/IU 3940 weeks head presentation,
with hypertension pregnancy
+ macrosomia. Patient came
to obstetry department with
abdominal pain (-), history
rupture of membrane (-),
Bloody slim (-), FM (+).
No history of DM, HT, allergy
and asthma.

12.30

LMP : 20/03/2014
EDD : 27/12/2014

History of ANC: 10x at PHC

Last ANC: 13th December 2014
Result : BW : 101,3 kg, BP :
130/90 mmHg, FHB : (+), head
presentation
USG history (-)
History of obstetry:
I. aterm/female/3600 gr/
II.
III. this

OBJECTIVE
General Status :
GC : well
GCS: CM
BP : 120/70 mmHg
PR : 84 bpm
RR : 22 bpm
Temp : 36,7oC

Eye : palor -/-, icteric -/Cor : S1S2 single reguler, murmur

(-), gallop (-).
Pulmo : vesikuler (+/+), wheezing
(-/-),
ronkhi (-/-).
Abdomen : scar (-), striae (+),
linea nigra (+).
Extremity : edema (-/-), warm
acral (+/+).
Obstetrical Status :
L1 : breech
L2 : back on the right side
L3 : head
L4 : 4/5
UFH : 38 cm
EFW : 4185 gram
UC : 2x10 ~ 35
FHR : 11-11-11 (137 bpm)

ASSESSMENT
G1P0A0H0 A/S/L/IU
head presentation
with laten phase +
history ROM

PLANNING
Observation
mother & fetal
well being.
DM co to GP
advice : obs.
Progress of labor,
inj. Ampicilin
1gr/6 hr

TIME

SUBJECTIVE

OBJECTIVE

Familiy planning history :

injection 3 month
Next family planning : injection
3 month

VT : 2 cm, eff 25 %, amnion (-)

clear, head palpable, HI,
impalpable small part of fetus /
umbilical cord.

Obstetrical history :
I. aterm, 3200gr, female,
spontan, midwfiery, life, 6years
II. this

Lab Examination :
HB : 11,7 g/dl
RBC : 3,90 x 106/L
HCT : 34,6 %
WBC : 11,08 x 103/L
PLT : 370 x 103/L
HbSAg : (-)

ASSESSMENT

PLANNING

TIME

SUBJECTIVE
Chronologist at Meninting PHC :
8th July 2014, 14.20 WITA
S : Patient came to meninting PHC
confessed abdominal pain since
13.00 WITA (8th July 2014), history
water lake out from her vagina (+)
since 21.00 WITA (7th July 2014),
Bloody slim (+), FM (+).
O:
GC : well (E4V5M6)
BP : 130/90 mmHg
PR : 82 bpm
RR : 22 x/minute
Temp : 36,5oC
Obstetrical status :
UFH: 38 cm
Head presentation, back at the right
EFW : 4185 gram
FHB: 132x/mnt (11-11-11)
UC : x10 ~ 35
VT : 2 cm, eff 25%, amnion (-)
clear, head palpable, denom
unkwon, HI, impalpable small part
of fetus / umbilical cord
A : G2P1A0L1 A/S/L/IU head
presentation with inpartu laten
phase and large EFW
P : obs. Mother and fetal well being
Obs. progress of labor
Meninting PHC referred to GH NTB

OBJECTIVE

ASSESSMENT

PLANNING

TIME

SUBJECTIVE

OBJECTIVE

17.30

General Status :
GC : well
GCS: CM
BP : 130/80 mmHg
PR : 80 bpm
RR : 22 bpm
Temp : 36,6oC

19.30

HIS : 4 x 10 ~ 45
FHR : 8-8-9 (100 x/m)
VT : 4cm, eff 75 %, amnion (-)
clear, head palpable, denom
LOT, HI, impalpable small part
of fetus / umbilical cord.

20.30

Mother wants to
bearing down

General Status :
GC : well
GCS: CM
BP : 140/90 mmHg
PR : 92 bpm
RR : 18 bpm
Temp : 36,6oC.
Urine : hematuri (80cc)
HIS : 4x10~40
DJJ : 8-8-10 (104 x/m)

ASSESTMENT

PLANNING
Observe mother & fetal well
being.
Suggest mother to eat and
drink

G2P1A0L1 A/S/L/IU
head presentation
with fetal distress

DM co to GP pro rescucitation
IU, GP co to SPV
Start partograf
Rescucitation Intrauterine (O2
5 lpm & infuse RL : D5% 2:1)
CTG
Mother lie on left side
Suggest mother to eat and
drink
CTG suspicious
DC
DM co to GP pro CS, GP co to
SPV, advice: obs. Mother and
fetal well being until 22.00
WITA

TIME

SUBJECTIVE

22.00

Mother wants to
bearing down

23.00

OBJECTIVE
General Status :
GC : well
GCS: CM
BP : 130/90 mmHg
PR : 80 bpm
RR : 20 bpm
Temp : 36,6oC.
HIS : 4x10~40
DJJ : 8-9-10 (108 x/m)
VT : complete, eff 100 %,
amnion (-) dried, head palpable,
denom LOT, caput (+),HI,
impalpable small part of fetus /
umbilical cord.

ASSESTMENT

PLANNING
DM co to GH, GH co to SPV,
advice : CS at 23.00
CIE patient and familiy, IUD
Pre-op patient:
Inj. Ceftriaxone 2gr/iv

CS begin (23.00)
Baby was born (23.10),
male, AS 7-9, 4150 gram, 52 cm,
Anus (+), congenital anomaly (-),
meconeal (+)
Placenta was born complete,
bleeding 350cc

TIME

SUBJECTIVE
01.15

OBJECTIVE
General Status :
GC : well
GCS: CM
BP : 140/90 mmHg
PR : 80 bpm
RR : 20 bpm
Temp : 36,5oC.
UC : (+) well
UFH : 2 fingers below
umbilicus
Active bleeding : (-)

ASSESTMENT
2 hours post CS

PLANNING
Observation mother and
baby well being
Suggest mother to eat
and drink
Suggest mother to
mobilitation